BOARDS & ROPES CAMP REGISTRATION PAGE
Participant Name
*
First Name
Last Name
Participant Phone Number
*
Participant Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Day/s at the Lake
July 7
July 14
July 21
July 28
August 4
Campus Life Club/School
*
Abington Heights
Blue Ridge
City Life
Crestwood
Dunmore
Elk Lake
Grove Church
Lackawanna Trail
Montrose
Mtn. View
North Pocono
Pen Argyl
Scranton
Susquehanna
Valley View
Wallenpaupack
Western Wayne
Other
Grade You're Going Into
*
Please Select
9
10
11
12
2023 grad!
Primary Emergency Contact Info
Primary Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Secondary Emergency Contact
Secondary Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Medical
In case of emergency
Name of Physician
*
First Name
Last Name
Physician Phone Number
*
-
Area Code
Phone Number
Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
I have had a physical within the last 24 months
Medical Insurance Company
*
Policy No.
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies (check all those that apply and specific nature of allergic reaction):
*
None
Animals
Environmental
Medication
Food
Insects
Latex
Other
Please specify the nature of allergic reaction
*
If none, type N/A
Consent and Release of Liability
Payment Options
Pay Online Now
I will bring cash/check payment to my Campus Life Leader by 8/4.
Other
Pay Online Now
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USD
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Parent/Guardian Name
*
Parent/Guardian Phone Number
*
Parent/Guardian Email
*
Signature:
*
I understand that by filling out this form and signing below, I am agreeing to pay the entire Registration Amount to attend this Campus Life Boards and Ropes Camp paid in full by 8/4.
Your Signature
*
Parent/Guardian Signature
*
Note:
Please verify that you are human
*
Submit
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